1. The document provides an overview of stroke rehabilitation and management. 2. The goal of rehabilitation is to allow patients to return to normal function by properly managing secondary disabilities like contractures and deconditioning. 3. Key factors that influence rehabilitation outcomes include the severity of neurological damage, presence of additional impairments like sensory or visual problems, and absence of depression.

1. AN OVERVIEW OF STROKE
Recent perspectives
DR. A.V. SRINIVASAN
“Knowledge can be communicated but not Wisdom”
- Hermann Hesse

2. Introduction
 Improved technology and treatment for stroke
has decreased mortality and prolonged survival
but disability from stroke remain Major health
care concern.
 Although Rehabilitation is one of the oldest forms
of treatment, it is least understood. Some
physicians uneasiness with rehabilitation has its
origin in Medical Training. Traditional Medical
training emphasis on diagnosis and curative
treatment. When cure is not possible patient
needs Rehabilitation Therapy, Counseling and
Support in the face of physical disability, feeling
of failure and futility.

3. “The True Art of Memory is
The Art of Attention” - S.Johnson
Injured Brain
25% men
1. 45 85 yrs - Stroke occurs
20% women
2. Guidelines for 24hrs: Mandatory
Level of Evidence
Level A: Based on RCT or Meta analy. of RCT
Level B: Based on Robust Experiment or
Observation Studies
Level C: Based on Expert opinion.

4. According to WHO
Doctor assessment of Handicap may not coincide with Patients
Assessment. Neurologist depends on physiotherapy, occupation
therapy and speech therapy in rehabilitating the stroke patients.

5. NEUROLOGIC PREDICTORS.
 Flaccid Paralysis for more than 96 hrs
 When tendon reflexes recover without return of voluntary
movement – prognosis poor
 Recovery of sensory less in usual to a degree. Postion
sense recovers but not pain and temperature
 Recovery from Dysphasia is never complete
 Dysarthria usual improves and Dysphagia never improves
 Diplopia due to brain stem is usually permanent
 Conjugate gaze – recovers
 Vertigo improves but hearing loss is permanent
 Pseudobulbar palsy permanent

6. REHABILITATION OF
STROKE
 Assessment of function
 Motor, postural, perceptual, cognitive,
communication and autonomic
 Independence and self-care
 Walking dressing washing, toileting and feeding
 Available services
 Nursing
 Physiotherapy
 Occupational therapy
 Clinical psychology
 Medical social worker plus self-help groups (‘Stroke
Club’)

7. EARLY MANAGEMENT AND
REHABILITATION
 Consist of
1. Skin care
2. IV therapy in disabled patients
3. Caution due to confusion
4. Auditory and visual deficit
5. Splint and braces
6. Complications include the following

8. Complications include the
following:
A. Contractures

9. Complications include the
following:
b. Treatment of Spasticity
TREATMENT MODALITIES FOR SPASTICITY
Surgery
Nerve Blocks
Motor Point Blocks
Drugs: Dantrolene, Baclofen, Diazepam
Muscle Stretching Program
Prevention of Nociception

10. Complications include the
following:
c. Reflex sympathetic Dystrophy
d. Physiological Deconditioning.
PHYSIOLOGICAL DECONDITIONING
Loss of Normal Postural
Reflexes
Increased Resting Pulse Rate
Catabolic Nutritional State-
Psychological Depression
Lower Vital Capacity
Slowing of GI Tract
Venous Stasis
Urinary Stasis

11. Complications include the
following:
e. Swallowing disorders
f. CVD and Heterotrophic ossification
7. Psychological factors

12. FACTORS GOVERNING THE
OUTCOME OF STROKE
REHAB.
 Good outcome –
 Mild to moderate neurologic damage
with mild moderate paresis not
associated with sensory or visual
problems
 Patients not demented or depressed

13. FACTORS GOVERNING THE
OUTCOME OF STROKE
REHAB.
 Walking 150 feet without assistances
(Goal )
 Motor alone – 0.9
 Motor Sensory Visual – 0.5
 Barthal index score – 95 normal
• Motor alone - 0.6
• Motor Sensory Visual – 0.5

14. FACTORS GOVERNING THE
OUTCOME OF STROKE
REHAB.
 Motor deficits alone reach their goals
within 12 weeks
 Framinham study – recovery from
stroke 3 months
 Adams – recovery from stroke 2
years

15. FUTURE TRENDS IN REHABILITATION
(Sensory Modulation)
 Anatomical Principles
 Somatosensory System
 Limbic System
 Visual System
 Phantom Experiences
 The man who missed his foot for penis
 Gaze Tinnitus
 Ear Lobe stimulation produces as an eroatic
sensation in nipple
 Phantom Pain

16. FUTURE TRENDS IN REHABILITATION
(Sensory Modulation)
 Role of Parietal Lobe
 Clinical Implications
 Synesthesia - Virtual reality box
 Allesthesia - Extinction of referred
sensation
 Caloric test - Disappearance of
Anosognosia

17. SUMMARY
 The goal of rehabilitation is to permit a
return to function. In pursuit of this goal,
proper management of secondary
disabilities is essential. Clinical objectives
include: prevention of contractures,
retardation of deconditioning,
maximization of nutritional status, optimal
treatment of associated medical
problems, and providing appropriate
psychological support to family and
patients.

18. 1. History And Examination
a. Stroke clerking Performa (1994) R.C.P.
1. Improved patient Assessment
2. Improved Management - not clear
3. Improved outcome - not clear
b. Examination
1. Secure Diag of Stroke
2. Specify Impairment
3. Identify sub type of Ischemic stroke
“ We Sometimes think we have forgotten something when
in fact we never really learned it in the first place”
Imp.Your Memory Skills

19. Through Action You Create your Own Education
- D.B. ELLIS
 Guide: 3 (B) - CPR
 Impaired Consciousness - From Stroke
Resuscitation is rarely successful Schneider
1993
 Guide: 4(B) Investigations:(Sagar
1995)- 435 PTS)
 Chest x-ray 16% ABN
 Only 4% change clinical management
 Order x-ray chest if WT Loss or chest
symptoms present

20.  Guide 5: (B) ECG:
 Cardiac cause of Death (30 days) Ebrahim 1990.
 All conscious patients to have ECG
 Guide 6: (C) CT:
 Routine CT Head is a Intell lazy approach
 King’s fund forum(1988) gives useful framework
 Weir 1994 Clinical scoring cannot distinguish
Do CT if a) Uncertainty of Stroke
b) If Anticoagulation or Anti Platelet
treatment contemplated

21.  Guide 7:(B) M.R.I.
 Moha 1995, - Unclear for Implications
for clinical practice
 No Routine MRI indication in Acute
Stroke
Whatever the Mind can conceive and Believe,
the mind can Achieve
Napoleon Hill

22. Imagination is more
Important than Knowledge
 Guide 8: (B) ECHO no Routine
 Echo in Acute Stroke
 TOE Vs. TTE
 Amer Heart Asson (1997) - same
conclusion
 Yield is very low. (Leung 1993;
Chambors 1997)
 Only when ABN ECGS - change clinical
management

23.  Guide 9: (A) - Dopp scan for
selected PTS:
 80% > more benefits from
Endarterectomy
 Minor stroke -No disability
 Subst Storke -Good recovery do
doppler
 Medically fit

24.  Guide 10: (B) Management:
 Fever (Worst Prog.) Reith 1996
 Hypoxia ( Moroney 1996) - Exac. by seizures
Pneumonia and Arrythmias - Worst outcome
 Hyperbaric O ineffective (Nighoghossaln
2
1995)
 Haemodilut. Plasm Expanders; venesection
 No evidence for efficacy (As plund - 1997)
Check ABG only if Hypoxia suspected.

25.  Guide 11: (A) Steroids and
Hyperosmolar agents Unproven
treatment - should not be used
 Tumor oedma responds but not
cytotoxic stroke oedma qialbash 1997
- No effect on survival or improv. In
funct. Outcome
 Manntol - (Boysen 1997) - short term
effective statistically in conclusive
You are what you think and not
what you think you are
Annoymous

26. We learn by thinking and the quality of the learning
outcome is determined by the quality of our
thoughts
R.B. Schmeck
 Guide 12: (B) - Blood Pressure
 Defer - acute reduction of BP - 10 days unless
HT Encephalopathy or adrtic dissection
present
 Moris 1997 - Increase BP - falls in 10 days
 UK - 5mm in D.B.P. 1/3 storke - Low BP
prompt correct of hypovoll. and withdrawal of
hypotonic drugs
 Collins 1994 - HT - Prim. stroke prevent
 Neal 1996 (Current RCT) - HTs in stroke
survivors -study needed

27.  Guide 13: (A/B) - AF
 AF / ISCH Stroke/ Mild disability -
warfarin after 48 Hrs (Longer for larger)
 Aspirin for others
 EAFT 1995 Less than 2 PT - No
effect
 SPAF 1996 > 5 - Bleeding

28.  Guide 14:(B/C) - Blood sugar
 Weir (1997) > 8 mm d/Lit - Poor
outcome
 Acute MI + 11 mm d/Lit - Intensive
Insulin - improved (Malmberg 1997)
A great many people think they are
thinking when they are merely re
arranging their prejudices
W. James

29. Many Ideas grow better when transplanted into
another mind than in the one where they sprang
UP
O.W. Holmos
 Guide 15: (A) Cholesterol
 Prosp. Study collob.: 1993 - Epidem
study do not support
 Blaun 1997: Metranauetic - Chollest &
statin 30% decrease - stroke in CAHD
patients.
 Sacks 1996 - Tot chol: decrease to 4.8
mmol/Lit benefits

30.  Guide 16: (A/C) Deep vein thrombosis
 Kalra 1995 - 10 days - stroke Pts - 50%
 Sandercock 1993 - Pul embol 6-16% only
 Ist 1997 - 5000 IV or 12500 twice daily -
Hemorrage greater
 Gradual stocking value - useful in Surg - pts
but its value not evaluated - (Wells 1994)
 Use with caution - if periph artery insuf. is
present hence do not use heparin on
stockings.

31.  Guide 17: (A/B) Pressure sure
 Event health care (1995) specialised
low pressure mattress systems to be
used than stand Hospital - mattress
Every discovery contains an
irrational element or 4 creative
intuition
Khrl Popper

32. I have never let my Medical schooling interfere with
my education
Mark Twain
 Manag of infarction
 Guide 18: (A)
• Aspirin 75 - 150 /Day
• 3 yrs 40% reduces of vascular events in
1000 pts (APTC - 1994)
• Stroke sub type value ? (TACI, PACI, LACI,
POCI)
• Dienners - 1996, synergy possibel with
clopidogrel ticlopidine etc.

33. Anti Coagulation
 Warfarin - AF
 In sinus rhythm - uncertain
 Spirit 1997 low dose ABP + Warfarin in
TIA & Minorstorke - Stopped of HE
 Heparin (IST 1997) - Signif. reduction
in early death (12 fewor in 1000) not
better than aspirin
 So avoid Heparin (A)

34.  Thrombolysis (A)
 Warlow 1997 - Uncertain clinical
benefit at the expense of greater
hazard avoid - thrombolysis
When they tell you to grow up,
they mean stop growing
P. Diccaso

35. A (Neurologist’s) life is like a piece of paper on
which everyone who passes by leaves an
impression
- Chines proverb
 Guide 20: (I) Hemorrhage
 Hankey and hon 1997: Supra tentorial
evacuation for ICH is controversial -
Avoid
 Infra tentorial - Yes
 Main Indication - Deteriorating or
depressed consciousness

36. 2 2 4 P ts
Guide 21 : Ventilation
131
I n t u b a tio n
93
N o t In tu b
-Decreased level of
consciousness - increased
6 4 D is c h a r 6 7 D ie d
mortality and poor final
3 4 R e d ta g 2 1 d is c h t o
n ver h om e
8 D is c fo r
p a llim a
1 D is c
H om e
outcome
- Absent pupillary light
3 D ie d 7 D ie d 3 D ie d
responses - poor prognosis
A medical school should not
be a preparation for life. A
school should be life

37. “By the deficits we may know the talents
By the exception we may discern rules
By studying the pathology,
We construct the model of health
And tools we need to affect our own life mould our
destiny,
Change ourselves and our society
In ways that as yet we can only imagine”
- Lawrence Miller

38. STROKE-TO-DEMENTIA
(Dr. A.V. Srinivasan, Dr. S. Balasubramanian,
Dr. R. Sowntharya, Dr. S. Rajesh)
Dr. A. V. Srinivasan
Addl. Prof. Of Neurology
Institute of Neurology,
Chennai.

39. Pathogenesis of dementia
due to SIVD
1. Lacunar hypothesis
2. Binswanger’s subtype of SIVD
3. VaD with coexisting Alzheimer’s
disease
Expert is one who think to his
chosen mode of ignorance

40. Two diverging/converging
pathways associated with SIVD
Risk factor CVD Ischemic Brain injury
MRI lesion Clinical syndrome
HTN
Arteriosclerosis 1. occlusion complete
infarct lacune  lacunnar state
Arteriosclerosis 2. Hypoperfusion
incomplete infarct WHSM 
Bingswanger syndrome
Experience can be defined as
yesterday’s answer to today’s problems

41. Clinical syndromes
1. Lacunar state --- 85%
2. Strategic infarct dementia(e.g.
thalamic dementia) --- unknown %
3. Binswanger’s syndrome ---
10 – 15%
Take time to think; it is the source of power
Take time to read; it is the foundation of wisdom
Take time to work; it the price of success

42. Features suggestive of
vascular dementia
From the history
Onset associated with a stroke
Improvement following acute event
Abrupt onset
From the exam
Findings typical of stroke e.g.,
hemiparesis, hemianopia
From imaging
Infarct(s) above the tentorium
Every thing should be made as simple as
possible; but not simpler

43. Categories of vascular
Dementia
Category Clinical presentation
Lacunar infarctions Progressive dementia, focal deficits, or
apathetic, frontal-lobe-like syndrome,
may have no stroke history
Single strategic Sudden onset aphasia, agnosia,
infarctions anterograde amnesia, frontal lobe
syndrome
Multiple infarctions Step-wise appearance of cognitive &
motor deficits
Mixed AD – VaD Progressive dementia with remote or
concurrent history of stroke
White matter Dementia, apathy, agitation, bilateral
infarctions cortico-spinal/bulbar signs
(Binswanger’s
disease)

44. NINDS-AIREN criteria for VaD
Probable vascular dementia : cognitive decline
from a previously higher level in three areas of
function including memory; evidence of
cerebrovascular disease by neurologic exam
and neuroimaging; onset of dementia either
abruptly or within 3 months of a recognized
stroke.
Possible vascular dementia : Dementia in the
absence of either neuroimaging evidence of
infarction or in the absence of a clear temporal
relationships between dementia and stroke.
NATURE, TIME AND PATIENCE
are the 3 great physicians

45. NINDS-AIREN criteria for VaD
contd…
AD with cerebrovascular disease : Patients
with possible AD who have imaging evidence
for infarction, or clinical history of stroke, both
of which appear incidental by clinical judgement
Definite vascular dementia : Probable vascular
dementia plus histopathological evidence of
infarction in the absence of other histological
markers of dementia (e.g., plaques, tangles,
pick bodies, etc.,)
Truth comes out of error sooner than that of confusion

46. Diagnostic criteria
1. Hachinski’s ischemic score
2. DSM IV criteria
3. ADDTC criteria
4. NINDS – AIREN criteria
5. Binswanger’s criteria
Opinion is ultimately determined by the feelings
and not by the intellect

47. Short comings
1. Not interchangeable hence four fold rise in
frequency
2. DSM IV R most liberal
3. NINDS- AIREN criteria conservative
4. Gold standard for VaD (pathological definition
difficult)
5. Most of the criteria failed to distinguish
between small and large vessel subtypes
“HealthyMind and Healthyexpression of
Emotion go hand in Hand”

48. Diagnosis and prognosis
Risk factors
Modifiable Non-modifiable
Hypertension Age
Hyperglycemia Gender
Race
Heredity
Discipline Weighs ounces
R egret weighs Tons

49. Diagnosis and prognosis
contd….
Vascular phenotype : “CVD”
 Arteriosclerosis
 Amyloid angiopathy
 Other small vessel disease
“Y have got to be before y can do
ou ou
and do before y can have”
ou

50. Diagnosis and prognosis
contd….
Vascular Mechanism of Pathological
distribution Brain injury phenotype
“Infarct”
Single artery Acute ischemia Multiple lacunar
Small arteriole infarcts
Single artery Acute ischemia Single
strategically
placed lacunar
infarct
Border zone Chronic White matter
Small arteriole hypo perfusion demyelination
and axonal loss

51. Diagnosis and prognosis
contd….
Neuro imaging phenotype
 CT lucency (lacunes and leukoariosis)
 MRI hyper intensity (lacunes and WMSH)
A true com itm is a heart felt prom to
m ent ise
yourself fromwhich y will not back down -
ou
D. Mcnally

52. Diagnosis and prognosis
contd….
Localisation / Clinical phenotype or syndrome
neural network
Cortico-basal ganglia – Lacunar state
thalamocortical loops Apathy, depression, abulia
Dysexecutive syndrome
Normal visual fields
parkinsonism
Cortico-basal ganglia Strategic infarct dementia
thalamocortical loops Dysexecutive syndrome
Frontal lobe syndrome
Deep white matter Binswanger’s syndrome
connections Slowly progressive depression,
bradykinesia, dysexecutive syndrome, gait

53. Prognosis
1. Risk factors
 Advanced age
 Education
Develops dementia
 Lacunar subtype following ischemic
 Lt. Hemisphere CVA stroke
 Non white
“ Fools Adm but of m of sense approve”
ire en
- A. Pope

54. Prognosis contd….
2. In Lacunar stroke - Leukoariosis is
a poor prognosis
3. Recurrence of stroke
Hence
 Atrophy
 cognitive impairment
 WMSH are inter related in SIVD
“ Social Isolation is in itself a pathogenic
Factor for disease production”

55. Prevention & Treatment
Primary prevention
Control of risk factors in mid life
a. Framingham Heart Study
b. HASS
c. ARIC
d. Systolic hypertension in Europe double
blind trial
At twenty the will rules
At thirty the intellect
At forty Judgment

56. Prevention & Treatment
contd…
Secondary prevention
Below 135 mm of Hg cognitive impairment
 Presence of lacunes and white matter
changes may be used as a marker for
high risk group
 Little is known – for effectiveness in
other risk factors
A woman’s desire for revenge outlasts all her other emotions

57. Prevention & Treatment
contd…
Anti dementia drug trials (not based on
subtype of VaD)
Alkaloid derivatives
(hydergine or nicergoline)
Pentoxyfylline
Piracetam Modest benefit
Memantine
Donepezil
Gingko biloba
Thought is the labour of the intellect
Reverie is its pleasure

58. Role of RIVASTIGMINE
in SIVD
No.of patients : 10
Age group : 50 – 80 years
Female : 4
Male : 6
Most of them had diabetes and hypertension
Not based on subtype of VaD
30% showed remarkable cognitive, curative and
affective deficit
Future study needed
“ He who cannot forgive others destroy the bridge
s
over which he him m pass” - Annoy
self ust

59. Strategies to prevent –
STROKE-TO-DEMENTIA
 Treat hypertension optimally
 Treat diabetes
 Control hyperlipidaemia
 Persuade patients to cease smoking and
decrease alcohol intake
 Prescribe anticoagulants for atrial fibrillation
 Provide antiplatelet therapy for high risk
patients
A open foe may prove a curse ; but
a pretended friend is worse

60. Strategies to prevent –
STROKE-TO-DEMENTIA
contd…
 Perform carotid endarterectomy for severe (>70%)
carotid stenosis
 Use dietary control for diabetes, obesity and
hyperlipidaemia
 Recommend lifestyle changes (e.g., weight loss,
exercise, reduce stress, decrease salt intake)
 Intervene early for stroke and transient ischemic
attacks with neuroprotective agents (e.g.,
propentofylline, calcium channel antagosists,
N-methyl-D-aspartate receptor antagonists,
antioxidants)
 Provide intensive rehabilitation after stroke

61. READ not to contradict or confute
Nor to Believe and Take for Granted
but TO WEIGH AND CONSIDER
THANK YOU